Attachment_J.3-E_TO_0002_Business_Proposal_Forms_Case_Review_7.17.18.xlsx

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Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) (BFCC-QIO)
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75FCMC18R0034
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Attachment J.3-E TO 0001 Business Proposal Forms red-lined 7.17.18

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Case_Review_FBO_Notice.pdf PDF
NCORC_FBO_Award_Notice.pdf PDF
BFCC_FBO_Award_Notice.pdf PDF
75FCMC18R0034_Amendment_3.pdf PDF
AMENDMENT_3_Summary.docx DOCX document
Q&A_7-17-18.xlsx XLSX spreadsheet
Attachment_J.2-F_TO_0001_Business_Proposal_Instructions_BFCC_NCORC_red-lined_7.17.18.docx DOCX document
AMENDMENT_2_Summary.docx DOCX document
75FCMC18R0034_Amendment_2.pdf PDF
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Attachment_J.2-F_TO_0001_Business_Proposal_Instructions_BFCC_NCORC_red-lined_6.29.18.docx DOCX document
Attachment_J.3-E_TO_0002_Business_Proposal_Forms_Case_Review_6.29.18.xlsx XLSX spreadsheet
Attachment_J.2-C_TO_0001_Evaluation_and_Audit_Measures_Table_BFCC_NCORC_red-lined_6.29.18.docx DOCX document
Attachment_J.2-A_TO_0001_Statement_of_Work_BFCC_NCORC_red-lined_6.29.18.docx DOCX document
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Attachment_J.2-E_TO_0001_Business_Proposal_Forms_6.29.18.xlsx XLSX spreadsheet
AMENDMENT_1_Summary.docx DOCX document
Attachment_J.3-A_TO_0002_Case_Review_SOW_red-lined_6.29.18.docx DOCX document
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75FCMC18R0034_Amendment_1.pdf PDF
Attachment_J.3-F_TO_0002_Business_Proposal_Instructions_Case_Review_red-lined_6.29.18.docx DOCX document
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BFCC_RFP_75FCMC18R0034_red-lined_6.29.18.docx DOCX document
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Attachment_J.3-B_TO_0002_Case_Review_SOD.docx DOCX document
Attachment_J.1_BFCC_IDIQ_Statement_of_Work.docx DOCX document
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Attachment_J.2-D_TO_0001_Proposal_Instructions_and_Eval_Criteria_BFCC_NCORC.docx DOCX document
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Attachment_J.3-C_TO_0002_Evaluation_Measures_Table.docx DOCX document
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BFCC Sup Sch Total

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: EMTALA Reviews23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day25. Focused Reviews26. Immediate Advocacy27. Sanction Activities28. Quality Improvement Initiatives and Technical Assistance29. Discrimination Referrals30. Other Non-Review Activities31. Legal and Regulatory Affairs32. Memorandums of Agreement and Joint Operating Agreements33. Internal Quality Assurance and Surveillance34. Training Medical Staff35. Training Other Personnel36. Information Services37. Collaboration38. Transparency Through Reporting39. BFCC Transition Costs40. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURS
a. LABOR:
1.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
2.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
3.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
4.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
5.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
6.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
7.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
8.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
9.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
10.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
11.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
12.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
13.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
14.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
15.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
16.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
17.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
18.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
19.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
41.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
42.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
43.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
44.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
45.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
46.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
47.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
48.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
49.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
50.0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
b. Leave0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
c. Fringe Benefits0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
2. Other Consultants0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
3. Other Subcontractors0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
e. Travel0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
f. Other Direct Costs0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
G&A$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
Overhead$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0
Projected Volume - # of cases for:
Year 10000000000000000000000000
Year 20000000000000000000000000
Year 30000000000000000000000000
Year 40000000000000000000000000
Year 50000000000000000000000000
i. Pass-thru Costs

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR1

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
From:
To:

5. Call Center /Beneficiary Helpline 6. Case Review Intake: Quality of Care Review Complaints 7. Quality of Care Review Complaints 8. Quality of Care Reviews Referred 9. Quality of Care Review Reconsiderations 10. Case Review Intake: Weichardt Appeals 11. Weichardt Appeals (FFS & Managed Care) 12. Case Review Intake: BIPA Appeals 13. Expedited Appeals BIPA 14. Case Review Intake: Grijalva Appeals 15. Expedited Appeals: Grijalva 16. Case Review Intake: Hospital Requested Review 17. Hospital Requested Reviews (HHR) 18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN) 19. Hospital Issued Notice of Non-Coverage (HINN) Reviews 20. Case Review Intake: Medical Necessity Reviews 21. Medical Necessity Reviews 22. Case Review Intake: EMTALA Reviews 23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day 24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day 25. Focused Reviews 26. Immediate Advocacy 27. Sanction Activities 28. Quality Improvement Initiatives and Technical Assistance 29. Discrimination Referrals 30. Other Non-Review Activities 31. Legal and Regulatory Affairs 32. Memorandums of Agreement and Joint Operating Agreements 33. Internal Quality Assurance and Surveillance 34. Training Medical Staff 35. Training Other Personnel 36. Information Services 37. Collaboration 38. Transparency Through Reporting 39. BFCC Transition Costs 40. Offsite Storage 45. Total

HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:j. Hourly Rate
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
G&A$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
Overhead$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 1
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR2

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: EMTALA Reviews23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day25. Focused Reviews26. Immediate Advocacy27. Sanction Activities28. Quality Improvement Initiatives and Technical Assistance29. Discrimination Referrals30. Other Non-Review Activities31. Legal and Regulatory Affairs32. Memorandums of Agreement and Joint Operating Agreements33. Internal Quality Assurance and Surveillance34. Training Medical Staff35. Training Other Personnel36. Information Services37. Collaboration38. Transparency Through Reporting39. BFCC Transition Costs40. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:j. Hourly Rate
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
G&A$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
Overhead$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 2
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR3

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: EMTALA Reviews23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day25. Focused Reviews26. Immediate Advocacy27. Sanction Activities28. Quality Improvement Initiatives and Technical Assistance29. Discrimination Referrals30. Other Non-Review Activities31. Legal and Regulatory Affairs32. Memorandums of Agreement and Joint Operating Agreements33. Internal Quality Assurance and Surveillance34. Training Medical Staff35. Training Other Personnel36. Information Services37. Collaboration38. Transparency Through Reporting39. BFCC Transition Costs40. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:j. Hourly Rate
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0$0$00.0$0$0$00.0$0$0$0$0$0$0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
G&A$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
Overhead$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 3
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR4

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: EMTALA Reviews23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day25. Focused Reviews26. Immediate Advocacy27. Sanction Activities28. Quality Improvement Initiatives and Technical Assistance29. Discrimination Referrals30. Other Non-Review Activities31. Legal and Regulatory Affairs32. Memorandums of Agreement and Joint Operating Agreements33. Internal Quality Assurance and Surveillance34. Training Medical Staff35. Training Other Personnel36. Information Services37. Collaboration38. Transparency Through Reporting39. BFCC Transition Costs40. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:j. Hourly Rate
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
G&A$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
Overhead$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 4
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

BFCC Sup Sch YR5

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: EMTALA Reviews23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day25. Focused Reviews26. Immediate Advocacy27. Sanction Activities28. Quality Improvement Initiatives and Technical Assistance29. Discrimination Referrals30. Other Non-Review Activities31. Legal and Regulatory Affairs32. Memorandums of Agreement and Joint Operating Agreements33. Internal Quality Assurance and Surveillance34. Training Medical Staff35. Training Other Personnel36. Information Services37. Collaboration38. Transparency Through Reporting39. BFCC Transition Costs40. Offsite Storage45. Total
HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:j. Hourly Rate
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. All Other (Non IT)0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
b. Leave
c. Fringe Benefits
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
d. SUBCONTRACTS:
1. Physician Reviewers / Phys. Advisors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
2. Other Consultants$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
3. Other Subcontractors$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0
e. Travel
f. Other Direct Costs$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0
SUBTOTAL - DIRECT0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0
g. Indirect Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
G&A$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
Overhead$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
TOTAL COSTS0.0$00.0$00.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$00.0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0$0$0ERROR:#DIV/0!0.0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!0.0$00.0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0$0
TOTAL COSTS WITH FEE$0$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!$0ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!ERROR:#DIV/0!$0$0$0$0$0$0$0$0$0$0$0$0$0
Projected Volume - # of cases for:
Year 5
i. Pass-thru Costs$0

GRAND TOTAL: $0 $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! $0 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ERROR:#DIV/0!

Add'l Labor Categ.

1. RFP Number:2. Name and Address of QIO Organization:3. QIO Service Area:4. Contract Period:
000From:12/31/99
0To:12/31/99
0
5. Call Center /Beneficiary Helpline6. Case Review Intake: Quality of Care Review Complaints7. Quality of Care Review Complaints8. Quality of Care Reviews Referred9. Quality of Care Review Reconsiderations10. Case Review Intake: Weichardt Appeals11. Weichardt Appeals (FFS & Managed Care)12. Case Review Intake: BIPA Appeals13. Expedited Appeals BIPA14. Case Review Intake: Grijalva Appeals15. Expedited Appeals: Grijalva16. Case Review Intake: Hospital Requested Review17. Hospital Requested Reviews (HHR)18. Case Review Intake: Hospital Issued Notice of Non-Coverage (HINN)19. Hospital Issued Notice of Non-Coverage (HINN) Reviews20. Case Review Intake: Medical Necessity Reviews21. Medical Necessity Reviews22. Case Review Intake: EMTALA Reviews23. Emergency Medical Treatment and Labor Act (EMTALA) 5-Day24. Emergency Medical Treatment and Labor Act (EMTALA) 60-Day25. Focused Reviews26. Immediate Advocacy27. Sanction Activities28. Quality Improvement Initiatives and Technical Assistance29. Discrimination Referrals30. Other Non-Review Activities31. Legal and Regulatory Affairs32. Memorandums of Agreement and Joint Operating Agreements33. Internal Quality Assurance and Surveillance34. Training Medical Staff35. Training Other Personnel36. Information Services37. Collaboration38. Transparency Through Reporting39. BFCC Transition Costs40. Offsite Storage45. Total

Year 1

HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
20. All Other (LABOR) :j. Hourly Rate
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.

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